to the editor: The editorial “It Won't Be Me Next Time: An Opinion on Preparticipation Sports Physicals”1 pointed out the limitations of the volunteer physician, assemblyline sports examinations performed in the gymnasium. A few years ago, the primary care physicians in our community gave up conducting assembly line physical examinations in our high school gymnasium. Our reasons are summarized in the editorial “Factors at Play in the Athletic Preparticipation Examination.”2 We could perform a better examination in our office, but most of all, we could establish a confidential venue for the discussion of athletic and nonathletic preventive issues for the present and the future. Chances are, this would be the only visit the student would have with a physician for the entire year.
We address parent and student cost concerns by conducting these examinations for a token fee of $25, or less for uninsured students. Moreover, although adolescents primarily relate to family physicians and pediatricians, we enroll the internal medicine and obstetrics–gynecology physicians to help meet the rush of students.
Interestingly, all 29 primary care physicians in our community participate each year. Their primary motivation is probably like mine, a crucial diagnostic or preventive episode that may occur during one of these visits. No medical literature addresses the value of preventive counseling at the time of an office sports physical examination, but each of us has our compelling anecdotes. The family nurse practitioner in our practice has hers—the girl who was having unprotected intercourse with her boyfriend and was afraid to tell her parents. Mine is the student who revealed his suicidal depression. Each year, we have more stories because as each student comes into the office, we take advantage of this important opportunity.
in reply: I appreciate receiving the interesting letter from Dr. Werra. I have received many interesting comments from family physicians all over the United States, many of whom agree with me. I am not opposed to primary care, family physicians, or even preparticipation clinic visits; my only point is that preparticipation sports physical examinations need to follow the same scientific and epidemiologic principles that govern all medicine. I stated in my editorial1 that there is a well-established indication for primary care and, as such, Dr. Werra seems to be saying that preparticipation sports physical examinations conducted with proper care and attention in his office are beneficial. Conducted under the appropriate setting, I have no doubt that they are as beneficial as the regular office visits that all children should receive regardless of their athletic prowess.
Dr. McKeag, in the opposing editorial,2 lists nine reasons for preparticipation sports physical examinations. The last eight reasons are nothing more than a duplication of primary care. The first reason is “ Legal conditions are met for the institution involved.” Is this another way of saying we have an obligation to assume the legal risks of educational institutions? For free no less? I take care of patients, not high schools. And I will take care of individual patients, in an individualized setting with testing available to me that meets the standard of care—and only when a clear goal and purpose exists for the office visit. In that sense, I could not agree with Dr. Werra more.
in reply: I truly enjoy the different perspectives that come forth when dealing with what can be a very controversial issue. Preparticipation physical examinations had, for many years, become simply a “necessary bother” to the physicians asked to perform them as a service to their community. In recent years, with the upgrade of the standards of care of athletes in general, the preparticipation sports physical examination has met with greater expectations. Because we have already stated our point in the editorial,1 let me just state that the methods used for screening are truly unimportant, as long as the screening is achieved in a manner conducive to consideration for nonathletic concerns and the collection of necessary valuable information to take care of the athlete. Perhaps I repeat myself when I say that no one should be performing these screening examinations unless they are competent and trained to do so. The preparticipation sports physical examination is too important and too valuable.
One final comment. While “the last eight reasons (for preparticipation sports physical examinations) are nothing more than a duplication of primary care,” they are also nothing more than a definition of good medical care. I think that's what we're all about, isn't it?